G Justus Hofmeyr

Fetal movement counting for assessment of fetal wellbeing

BACKGROUNDnFetal movement counting is a method by which a woman quantifies the movements she feels to assess the condition of her baby. The purpose is to try to reduce perinatal mortality by alerting caregivers when the baby might be compromised. This method may be used routinely, or only in women who are considered at increased risk of complications affecting the baby. Fetal movement counting may allow the clinician to make appropriate interventions in good time to improve outcomes. On the other hand, fetal movement counting may cause unnecessary anxiety to pregnant women, or elicit unnecessary interventions.nnnOBJECTIVESnTo assess outcomes of pregnancy where fetal movement counting was done routinely, selectively or was not done at all; and to compare different methods of fetal movement counting.nnnSEARCH METHODSnWe searched the Cochrane Pregnancy and Childbirth Groups Trials Register (31 May 2015) and reference lists of retrieved studies.nnnSELECTION CRITERIAnRandomised controlled trials (RCTs) and cluster-RCTs where fetal movement counting was assessed as a method of monitoring fetal wellbeing.nnnDATA COLLECTION AND ANALYSISnTwo review authors assessed studies for eligibility, assessed the methodological quality of included studies and independently extracted data from studies. Where possible the effects of interventions were compared using risk ratios (RR), and presented with 95% confidence intervals (CI). For some outcomes, the quality of the evidence was assessed using the GRADE approach.nnnMAIN RESULTSnFive studies (71,458 women) were included in this review; 68,654 in one cluster-RCT. None of these five trials were assessed as having low risk of bias on all seven risk of bias criteria. All included studies except for one (which included high-risk women as participants) included women with uncomplicated pregnancies.Two studies compared fetal movement counting with standard care, as defined by trial authors. Two included studies compared two types of fetal movement counting; once a day fetal movement counting (Cardiff count-to-10) with more than once a day fetal movement counting methods. One study compared fetal movement counting with hormone assessment.(1) Routine fetal movement counting versus mixed or undefined fetal movement countingNo study reported on the primary outcome perinatal death or severe morbidity. In one large cluster-RCT, there was no difference in mean stillbirth rates per cluster (standard mean difference (SMD) 0.23, 95% CI -0.61 to 1.07; participants = 52 clusters; studies = one, low quality evidence). The other study reported no fetal deaths. There was no difference in caesarean section rate between groups (RR 0.93, 95% CI 0.60 to 1.44; participants = 1076; studies = one,low quality evidence). Maternal anxiety was significantly reduced with routine fetal movement counting (SMD -0.22, 95% CI -0.35 to -0.10; participants = 1013; studies = one, moderate quality evidence). Maternal-fetal attachment was not significantly different (SMD -0.02, 95% CI -0.15 to 0.11; participants = 951; studies = one, low quality evidence). In one study antenatal admission after reporting of decreased fetal movements was increased (RR 2.72, 95% CI 1.34 to 5.52; participants = 123; studies = one). In another there was a trend to more antenatal admissions per cluster in the counting group than in the control group (SMD 0.38, 95% CI -0.17 to 0.93; participants = 52 clusters; studies = one, low quality evidence). Birthweight less than 10th centile was not significantly different between groups (RR 0.98, 95% CI 0.66 to 1.44; participants = 1073; studies = one, low quality evidence). The evidence was of low quality due to imprecise results and because of concerns regarding unclear risk of bias. (2) Formal fetal movement counting (Modified Cardiff method) versus hormone analysisThere was no difference between the groups in the incidence of caesarean section (RR 1.18, 95% CI 0.83 to 1.69; participants = 1191; studies = one). Women in the formal fetal movement counting group had significantly fewer hospital visits than those randomised to hormone analysis (RR 0.26, 95% CI 0.20 to 0.35), whereas there were fewer Apgar scores less than seven at five minutes for women randomised to hormone analysis (RR 1.72, 95% CI 1.01 to 2.93). No other outcomes reported showed statistically significant differences. Perinatal death or severe morbidity was not reported. (3) Formal fetal movement counting once a day (count-to-10) versus formal fetal movement counting method where counting was done more than once a day (after meals)The incidence of caesarean section did not differ between the groups under this comparison (RR 2.33, 95% CI 0.61 to 8.99; participants = 1400; studies = one). Perinatal death or severe morbidity was not reported. Women were more compliant in using the count-to-10 method than they were with other fetal movement counting methods, citing less interruption with daily activities as one of the reasons (non-compliance RR 0.25, 95% CI 0.19 to 0.32).Except for one cluster-RCT, included studies were small and used different comparisons, making it difficult to measure the outcomes using meta-analyses. The nature of the intervention measured also did not allow blinding of participants and clinicians..nnnAUTHORS CONCLUSIONSnThis review does not provide sufficient evidence to influence practice. In particular, no trials compared fetal movement counting with no fetal movement counting. Only two studies compared routine fetal movements with standard antenatal care, as defined by trial authors. Indirect evidence from a large cluster-RCT suggested that more babies at risk of death were identified in the routine fetal monitoring group, but this did not translate to reduced perinatal mortality. Robust research by means of studies comparing particularly routine fetal movement counting with selective fetal movement counting is needed urgently, as it is a common practice to introduce fetal movement counting only when there is already suspected fetal compromise.

Active management of the third stage of labour without controlled cord traction: a randomized non-inferiority controlled trial

BackgroundThe third stage of labour refers to the period between birth of the baby and complete expulsion of the placenta. Some degree of blood loss occurs after the birth of the baby due to separation of the placenta. This period is a risky period because uterus may not contract well after birth and heavy blood loss can endanger the life of the mother. Active management of the third stage of labour (AMTSL) reduces the occurrence of severe postpartum haemorrhage by approximately 60–70%. Active management consists of several interventions packaged together and the relative contribution of each of the components is unknown. Controlled cord traction is one of those components that require training in manual skill for it to be performed appropriately. If it is possible to dispense with controlled cord traction without losing efficacy it would have major implications for effective management of the third stage of labour at peripheral levels of health care.ObjectiveThe primary objective is to determine whether the simplified package of oxytocin 10 IU IM/IV is not less effective than the full AMTSL package.MethodsA hospital-based, multicentre, individually randomized controlled trial is proposed. The hypothesis tested will be a non-inferiority hypothesis. The aim will be to determine whether the simplified package without CCT, with the advantage of not requiring training to acquire the manual skill to perform this task, is not less effective than the full AMTSL package with regard to reducing blood loss in the third stage of labour.The simplified package will include uterotonic (oxytocin 10 IU IM) injection after delivery of the baby and cord clamping and cutting at approximately 3 minutes after birth. The full package will include the uterotonic injection (oxytocin 10 IU IM), controlled cord traction following observation of uterine contraction and cord clamping and cutting at approximately 3 minutes after birth. The primary outcome measure is blood loss of 1000 ml or more at one hour and up to two hours for women who continue to bleed after one hour. The secondary outcomes are blood transfusion, the use of additional uterotonics and measure of severe morbidity and maternal death.We aim to recruit 25,000 women delivering vaginally in health facilities in eight countries within a 12 month recruitment period.ManagementOverall trial management will be from HRP/RHR in Geneva. There will be eight centres located in Argentina, Egypt, India, Kenya, Philippines, South Africa, Thailand and Uganda. There will be an online data entry system managed from HRP/RHR. The trial protocol was developed following a technical consultation with international organizations and leading researchers in the field.Expected outcomesThe main objective of this trial is to investigate whether a simplified package of third stage management can be recommended without increasing the risk of PPH. By avoiding the need for a manual procedure that requires training, the third stage management can be implemented in a more widespread and cost-effective way around the world even at the most peripheral levels of the health care system. This trial forms part of the programme of work to reduce maternal deaths due to postpartum haemorrhage within the RHR department in collaboration with other research groups and organizations active in the field.Trial RegistrationACTRN12608000434392

Extended pre-exposure prophylaxis with lopinavir–ritonavir versus lamivudine to prevent HIV-1 transmission through breastfeeding up to 50 weeks in infants in Africa (ANRS 12174): a randomised controlled trial

BACKGROUNDnStrategies to prevent postnatal mother-to-child transmission of HIV-1 in Africa, including infant prophylaxis, have never been assessed past 6 months of breastfeeding, despite breastfeeding being recommended up to 12 months after birth. We aimed to compare the efficacy and safety of infant prophylaxis with the two drug regimens (lamivudine or lopinavir-ritonavir) to prevent postnatal HIV-1 transmission up to 50 weeks of breastfeeding.nnnMETHODSnWe did a randomised controlled trial in four sites in Burkina Faso, South Africa, Uganda, and Zambia in children born to HIV-1-infected mothers not eligible for antiretroviral therapy (CD4 count >350 cells per μL). An independent researcher electronically generated a randomisation schedule; we then used sequentially numbered envelopes to randomly assign (1:1) HIV-1-uninfected breastfed infants aged 7 days to either lopinavir-ritonavir or lamivudine (paediatric liquid formulations, twice a day) up to 1 week after complete cessation of breastfeeding or at the final visit at week 50. We stratified the randomisation by country and used permuted blocks of four and six. We used a study label on drug bottles to mask participants, study physicians, and assessors to the treatment allocation. The primary outcome was infant HIV-1 infection between age 7 days and 50 weeks, diagnosed every 3 months with HIV-1 DNA PCR, in the modified intention-to-treat population (all who attended at least one follow-up visit). This trial is registered with ClinicalTrials.gov, number NCT00640263.nnnFINDINGSnBetween Nov 16, 2009, and May 7, 2012, we enrolled and randomised 1273 infants and analysed 1236; 615 assigned to lopinavir-ritonavir or 621 assigned to lamivudine. 17 HIV-1 infections were diagnosed in the study period (eight in the lopinavir-ritonavir group and nine in the lamivudine group), resulting in cumulative HIV-1 infection of 1.4% (95% CI 0.4-2.5) and 1.5% (0.7-2.5), respectively. Infection rates did not differ between the two drug regimens (hazard ratio [HR] of lopinavir-ritonavir versus lamivudine of 0.90, 95% CI 0.35-2.34; p=0.83). Clinical and biological severe adverse events did not differ between groups; 251 (51%) infants had a grade 3-4 event in the lopinavir-ritonavir group compared with 246 (50%) in the lamivudine group.nnnINTERPRETATIONnInfant HIV-1 prophylaxis with lopinavir-ritonavir was not superior to lamivudine and both drugs led to very low rates of HIV-1 postnatal transmission for up to 50 weeks of breastfeeding. Infant pre-exposure prophylaxis should be extended until the end of HIV-1 exposure and mothers should be informed about the persistent risk of transmission throughout breastfeeding.nnnFUNDINGnINSERM/National Agency for Research on AIDS and Viral Hepatitis (including funds from the Total Foundation), European Developing Countries Clinical Trials Partnership, Research Council of Norway.

Preeclampsia in Low and Middle Income Countries—Health Services Lessons Learned From the PRE-EMPT (PRE-Eclampsia–Eclampsia Monitoring, Prevention & Treatment) Project

The hypertensive disorders of pregnancy, in particular preeclampsia, matter because adverse events occur in women with preeclampsia and, to a lesser extent, in women with the other hypertensive disorders. These adverse events are maternal, perinatal, and neonatal and can alter the life trajectory of each individual, should that life not be ended by complications. In this review we discuss a number of priorities and dilemmas that we perceive to be facing health services in low and middle income countries as they try to prioritize interventions to reduce the health burden related to preeclampsia. These priorities and dilemmas relate to calcium for preeclampsia prevention, risk stratification, antihypertensive and magnesium sulphate therapy, and mobile health. Significant progress has been and is being made to reduce the impact of preeclampsia in low and middle income countries, but it remains a priority focus as we attempt to achieve Millennium Development Goal 5.

Improving maternal and perinatal outcomes in the hypertensive disorders of pregnancy: A vision of a community-focused approach

The hypertensive disorders of pregnancy (HDP; pre‐existing hypertension, gestational hypertension, and pre‐eclampsia) remain important causes of maternal morbidity and mortality, especially in low‐ and middle‐income countries. The paper summarizes the current state of evidence around possible technologies to support community‐based improvements in maternal and perinatal outcomes for women with pre‐eclampsia. Through the testing and, where proven, introduction of these technologies, we believe that HDP‐related progress toward achieving Millennium Development Goal 5 can best be accelerated. The evidence and discussion are presented under the following headings: (1) prediction; (2) prevention; (3) diagnosis; (4) risk stratification; (5) decision aids; (6) treatment; (7) geographic information systems; (8) communication; and (9) community and patient education.

The effect of depot medroxyprogesterone acetate on postnatal depression: a randomised controlled trial.

Background Depot medroxyprogesterone acetate (DMPA) is the most commonly used hormonal contraceptive method in South Africa. It is frequently administered in the immediate postnatal period, yet it is unclear whether it affects the risk of postnatal depression (PND). Aim To determine whether DMPA increases the risk of PND compared with the copper-containing intrauterine device (IUD) when administered after delivery. Design and setting A single-blind randomised controlled trial conducted at two teaching hospitals in East London, South Africa. Methods Eligible, consenting women (N=242) requiring postnatal contraception were randomised to receive DMPA or an IUD within 48u2005hours of childbirth and interviewed at 1 and 3 months postpartum. Depression was measured using the Beck Depression Inventory (BDI-II) and the Edinburgh Postnatal Depression Scale (EPDS). Resumption of sexual intercourse, menstrual symptoms and breastfeeding rates were also assessed. Results One-month EPDS depression scores were statistically significantly higher in the DMPA arm compared with IUD arm (p=0.04). Three-month BDI-II scores were significantly higher in the DMPA arm than in the IUD arm (p=0.002) and, according to the BDI-II but not the EPDS, more women in the DMPA arm had major depression at this time-point (8 vs 2; p=0.05). There were no statistically significant differences in other outcome measures except that fewer women had resumed sexual activity by 1u2005month postpartum in the DMPA arm (13% vs 26%; p=0.02). Conclusions The possibility that immediate postnatal DMPA use is associated with depression cannot be excluded. These findings justify further research with longer follow-up. Clinical trial number PACTR201209000419241.

Oral misoprostol is as safe as Foley catheter for labour induction…or is it?

www.thelancet.com Published online February 2, 2016 http://dx.doi.org/10.1016/S0140-6736(15)01042-9 1 In The Lancet, the researchers of the PROBAAT-II study pass another milestone on the long and circuitous evolution of methods to ripen the uterine cervix during induction of labour. Before there were prostaglandins, there were mechanical methods. One was a simple Foley catheter bulb passed through the cervix and infl ated in the potential space between the amniotic sac and the uterus. In the decades following the introduction of dinoprostone vaginal gel, the Foley catheter method was all but forgotten. This is not surprising, given our enthusiasm for new and exciting drug treatments. And, unlike the rough and ready Foley catheter method, dinoprostone had a promotional budget. In the PROBAAT-II trial, women, scheduled for induction of labour and with an unfavourable cervix, were randomly assigned either to oral misoprostol (n=932) or to Foley catheter (n=927). The primary outcome (a composite of neonatal asphyxia or postpartum haemorrhage) occurred in 113 (12%) of 924 participants in the misoprostol group versus 106 (11%) of 927 in the Foley catheter group (adjusted relative risk 1·06, 90% CI 0·86–1·31). By the time the PROBAAT-II trial was designed, the authors had reinstated the Foley catheter as the gold standard method of induction, based on its favourable safety profi le compared with dinoprostone vaginal gel in the PROBAAT-I study. The method compared with the Foley catheter in the PROBAAT-II study was oral misoprostol. Designed as a gastrointestinal agent, misoprostol was conscripted for use in pregnancy in the late 1980s, giving health workers (and women) in lowresource settings aff ordable control over the duration of pregnancy for the fi rst time. It revolutionised global access to safe abortion. However, its adaptation for labour induction at term proved to be slow and costly. New drugs normally undergo stringent preclinical and early clinical studies to ensure safety and correct dosage. Misoprostol entered clinical practice for labour induction with none of these precautions, and with no package insert information on route of administration or dosage. Clinicians failed to anticipate the sensitivity with which the uterus would respond to stimulation by misoprostol. The vaginal route was assumed to be the most logical to achieve a direct eff ect on the cervix, and arbitrary dosages were chosen. The result was an epidemic of excessive uterine stimulation causing fetal distress or uterine rupture. To overcome the limitation of having only a 200 μg tablet, my colleagues and I developed a titrated oral misoprostol solution. We dissolved one tablet in 200 mL tap water and administered small volumes of the freshly mixed solution every 2 h by mouth. We initially used 20 mL (equivalent to 20 μg), titrating up to 40 mL if necessary. By the time the PROBAAT-II study was planned, there was some consensus that the oral route was safer than vaginal, and that 25 μg every 2 h or 50 μg every 4 h (the dose used in the PROBAAT-II study) was a reasonably safe dose. The primary concern of the PROBAAT-II study was safety. In terms of the composite primary outcome, oral misoprostol was non-inferior to Foley catheter. The authors concluded that oral misoprostol is an eff ective and safe alternative method. The fi ndings are certainly reassuring. However, there is scope for further interrogation of this conclusion. Rare but serious complications such as uterine rupture are diffi cult to measure even in large randomised trials (there were none in the PROBAAT-II study). The Foley catheter method, which avoids exogenous uterine stimulants and relies on the local release of endogenous prostaglandins, might inherently be more safe. The PROBAAT-II investigators point out that oral misoprostol might be an attractive option in low-resource settings, but that its use would require confi rmation by studies done in such settings. In settings without facilities for close monitoring of mother and baby during labour, avoidance of exogenous uterine stimulants could be an important safety consideration. Moreover, the 3·8-times greater incidence of spontaneous rupture of the membranes with oral misoprostol in the PROBAAT-II study might be disadvantageous in settings with a high prevalence of HIV and other infections. A benefi t of oral misoprostol is avoidance of the vaginal procedure needed to place a Foley catheter. However, in the PROBAAT-II study, fewer vaginal examinations were required in the Foley catheter group. Oral misoprostol is as safe as Foley catheter for labour induction...or is it?

Breastfeeding patterns and its determinants among mothers living with Human Immuno-deficiency Virus -1 in four African countries participating in the ANRS 12174 trial

BackgroundHIV-1 transmission rates have been reduced over the last decade, an estimated 2 million new infections per year arise, including 220,000 paediatric cases. The main post-natal HIV exposure is through breastfeeding, where both its duration and modality (exclusive or not) are associated with postnatal transmission. The ANRS 12174 trial compared HIV-1 postnatal transmission of 2 prophylaxis drugs for infants during lactation (lamivudine and lopinavir-ritonavir). Our objective has been to examine the feeding practices and the determinants of exclusive/ predominant (EPBF) or any breastfeeding among the participants of this trial in Burkina Faso, South Africa, Uganda and Zambia.MethodsMothers infected with HIV-1 and their uninfected offspring were followed from day 7 after birth for 50xa0weeks, keeping monthly records of their feeding patterns. Feeding was classified into 3 categories: 1) exclusive breastfeeding during the first six months, only breast-milk being given to infant for 6xa0months, 2) predominant breastfeeding, breast-milk with liquid-based items being given, and 3) mixed feeding, other non-breast milk or solid food being given in addition to breast milk with or without liquid-based items. The categories were merged into 2 groups: EPBF applying to infants aged <6xa0months and mixed feeding applying to infants of any age. The feeding patterns have been given as Kaplan-Meier curves. A flexible parametric multiple regression model was used to identify the determinants of the mothers’ feeding behaviour.ResultsA total of 1,225 mother-infant pairs provided feeding data from Burkina Faso (Nu2009=u2009204), South Africa (Nu2009=u2009213), Uganda (Nu2009=u2009274) and Zambia (Nu2009=u2009534) between November 2009 and March 2013. The mean maternal age was 27.4xa0years and the mean BMI was 24.5. 57.7 and 93.9% of mothers initiated breastfeeding within the first hour and first day, respectively. Overall, the median durations of any form of breastfeeding and EPBF were 40.6, and 20.9xa0weeks, respectively. Babies randomized to the lopinavir/ritonavir group in South Africa tended to do less EPBF than those in the lamivudine group.Overall the group of mothers aged between 25 and 30xa0years, those married, employed or multiparous tended to stop early EPBF. Mothers living in Uganda or Zambia, those aged between 25 -30xa0years, better educated (at least secondary school level), employed or having undergone C-section stopped any breastfeeding early.ConclusionsThere is a need to improve breastfeeding and complementary feeding practices of children, particularly those exposed to HIV and anti-retrovirals, taking into account context and socio-demographic factors.Trial registrationClinical trial registration: NCT00640263.

Amnioinfusion for chorioamnionitis.

BACKGROUNDnChorioamnionitis is a leading cause of perinatal morbidity and mortality. Amnioinfusion aims at reducing the adverse effects of chorioamnionitis by dilution of the infective organisms or by an anti-microbial effect of the fluid infused.nnnOBJECTIVESnThe objective of this review was to determine the effect of amnioinfusion on clinical and sub-clinical chorioamnionitis, fetal well-being, fetal heart rate characteristics and perinatal and maternal morbidity and mortality.nnnSEARCH METHODSnWe searched the Cochrane Pregnancy and Childbirth Groups Trials Register (6 July 2016), PubMed, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (6 July 2016) and reference lists of retrieved studies.nnnSELECTION CRITERIAnRandomised clinical trials (RCTs) of amnioinfusion (treatment group) versus no amnioinfusion in women with chorioamnionitis.We would have also considered trials comparing amnioinfusion with sham amnioinfusion; different types or volumes of amnioinfusion fluid but none were identified.Cluster-RCTs and quasi-RCTs were eligible for inclusion but none were identified. We identified one study published in abstract form but it did not contain any numerical data and has therefore been excluded. Studies using a cross-over design are not an appropriate study design and thus were not eligible for inclusion in this review.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently assessed potential studies for inclusion and assessed trial quality. Both review authors independently extracted data and data were checked for accuracy.nnnMAIN RESULTSnWe included one small trial (with data from 34 participants) comparing transcervical amnioinfusion with no amnioinfusion. The trial was considered to be at a high risk of bias overall, due to small numbers, inconsistency in the reporting and lack of information on blinding. Meta-analysis was not possible. Transcervical amnioinfusion was with room temperature saline at 10 mL per minute for 60 minutes, then 3 mL per minute until delivery versus no amnioinfusion. All women received intrauterine pressure catheter, acetaminophen and antibiotics (ampicillin or, if receiving Group B beta streptococcal prophylaxis, penicillin and gentamycin). We did not identify any trials that used transabdominal amnioinfusion.Compared to no amnioinfusion, transcervical amnioinfusion had no clear effect on the incidence of postpartum endometritis (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.29 to 7.87; absolute risk 176/1000 (95% CI 34 to 96) versus 118/1000;low-quality evidence). Nor was there a clear effect in the incidence of neonatal infection (RR 3.00, 95% CI 0.13 to 68.84; absolute risk 0/1000 (95% CI 0 to 0) versus 0/1000; low-quality evidence). The outcome of perinatal death or severe morbidity (such as neonatal encephalopathy, intraventricular haemorrhage, admission to intensive/high care) was not reported in the included trial.In terms of this reviews secondary outcomes, the rate of caesarean section was the same in both groups (RR 1.00, 95% CI 0.35 to 2.83; absolute risk 294/1000 (95% CI 103 to 832) versus 294/1000; low-quality evidence). There was no clear difference in the duration of maternal antibiotic treatment between the amnioinfusion and no amnioinfusion control group (mean difference (MD) 16 hours, 95% CI -1.75 to 33.75); nor in the duration of hospitalisation (MD 3.00 hours, 95% CI -15.49 to 21.49). The study did not report any information about how many babies had a low Apgar score at five minutes after birth.Women in the amnioinfusion group had a lower temperature at delivery compared to women in the control group (MD -0.38°C, 95% CI -0.74 to -0.02) but this outcome was not pre-specified in the protocol for this review.The majority of this reviews secondary outcomes were not reported in the included study.nnnAUTHORS CONCLUSIONSnThere is insufficient evidence to fully evaluate the effectiveness of using transcervical amnioinfusion for chorioamnionitis and to assess the safety of this intervention or womens satisfaction. We did not identify any trials that used transabdominal amnioinfusion. The evidence in this review can neither support nor refute the use of transcervical amnioinfusion outside of clinical trials. We included one small study that reported on a limited number of outcomes of interest in this review. The numbers included in this review are too small for meaningful assessment of substantive outcomes, where reported. For those outcomes we assessed using GRADE (postpartum endometritis, neonatal infection, and caesarean section), we downgraded the quality of the evidence to low - with downgrading decisions based on small numbers and a lack of information on blinding. The included study did not report on this reviews other primary outcome (perinatal death or severe morbidity).The reduction in pyrexia, though not a pre-specified outcome of this review, may be of relevance in terms of benefits to the fetus of reduced exposure to heat. We postulate that the temperature reduction found may be a direct cooling effect of amnioinfusion with room temperature fluid, rather than reduction of infection. Larger trials are needed to confirm and extend the findings of the trial reviewed here. These should be randomised controlled trials; participants, women with chorioamnionitis; interventions, amnioinfusion; comparisons, no amnioinfusion; outcomes, maternal and perinatal outcomes including neurodevelopmental measures.Further research is justified to determine possible benefits or risks of amnioinfusion for chorioamnionitis, and to investigate possible benefits of reducing temperature in fetuses considered at risk of neurological damage. Research should include randomised trials to examine transcervical or transabdominal amnioinfusion compared with no infusion for chorioamnionitis and examine outcomes listed in the methods of this review.

Prevention of postpartum hemorrhage in the absence of uterotonics

Although effective methods to prevent postpartum hemorrhage are available, deaths from postpartum hemorrhage remain most common in areas where access to health services is poorest. Global access to uterotonic drugs is unachievable in the foreseeable future, and questions of safety and dosage of other methods remain to be resolved [1]. The need exists to investigate simple measures which can be applied universally at the community level to reduce the global burden of postpartum haemorrhage.